Targeting smoking cessation efforts

A hospital stay is a window of opportunity to help patients quit smoking, and hospitalists
are well positioned to take advantage of it.

There's good reason to go the extra mile in providing smoking cessation therapies—recent
studies suggest that nicotine addiction is undertreated, even among high-risk inpatients.
In a national registry study, 97% of smokers hospitalized with myocardial infarction
(MI) were counseled to quit smoking, but only 7% filled a prescription for varenicline
or bupropion within 90 days after discharge.

Photo by Thinkstock.

“Although these medications are certainly not the right answer for every patient,
they are likely to be useful in more than just 7% of patients with a recent MI,”
said study author Neha Pagidipati, MD, a cardiologist and assistant professor of medicine
at Duke University School of Medicine in Durham, N.C.

Inpatients were significantly more likely to fill prescriptions if they were younger,
were female, lived in areas with above-average high school graduation rates, had chronic
obstructive pulmonary disease (COPD) or peripheral arterial disease, or underwent
revascularization in the hospital, Dr. Pagidipati and her colleagues reported in the
September 2017 JAMA Cardiology.

Such findings suggest a need to target therapies, experts said. “I believe
that clinicians can best match smoking cessation methods to individual patients by
having a conversation with them, and seeing what patients are interested in and able
to participate in,” said Dr. Pagidipati. “For example, some patients
may not have the time to participate in counseling, while others may be completely
uninterested in taking medication.”

Who's most—and least—likely to quit

Demographic and clinical factors can tip the scales toward or against a successful
quit attempt. Gender is a major modifier, experts said. “We know that women
have more difficulty quitting smoking than men, and they also have different concerns
and barriers to quitting,” said Natacha De Genna, PhD, an assistant professor
of psychiatry and epidemiology at the University of Pittsburgh School of Medicine.

Studies show that women are more likely than men to report using e-cigarettes to regulate
mood and manage stress and body weight, she noted. “It's important for clinicians
to be aware of those concerns and address them in smoking cessation counseling.”

Female inpatients also are more likely than men to use e-cigarettes, and often do
so to try to reduce or quit traditional cigarette use. The prevalence of e-cigarette
use was 22% in a cross-sectional study of tobacco users Dr. De Genna and her colleagues
published in the November/December 2017 Journal of Addiction Medicine, but the majority of the female patients had used them.

In the study, users of e-cigarettes tended to be younger and female and started smoking
earlier in life, but smoked as much and as often as other study participants, said
Dr. De Genna. “These patients may benefit most from directed discussions about
the use of evidence-based, FDA-approved therapies for smoking cessation.”

Gender also seems to modify the efficacy of specific treatments. A population-based
study found the nicotine patch to be significantly more effective than no smoking
cessation treatment for male smokers, but not for women. Conversely, varenicline significantly
outperformed no treatment for women who smoked, but not men. These findings match
trial data and highlight the need to consider gender when offering treatment for smoking
cessation, the study authors wrote in the September 2017 Drug and Alcohol Dependence.

Studies have also shown that hospitalization for a smoking-related condition such
as MI increases the chances that patients will quit smoking after discharge. “Given
the clear link between cardiac events and current smoking, it makes sense to target
these patients aggressively, and this is a cost-effective approach,” said Anne
Melzer, MD, an assistant professor in the division of pulmonary, allergy, sleep and
critical care medicine at the University of Minnesota in Minneapolis.

Pneumonia is another common reason for hospitalization and often is smoking-related,
but patients typically don't know this, Dr. Melzer said. Discussing this link as part
of smoking cessation counseling can help patients move toward quitting, she added.

But the health benefits of cessation aren't the factor that motivates many inpatients
to successfully quit, cautioned Frank Leone, MD, director of the Comprehensive Smoking
Treatment Program at the University of Pennsylvania in Philadelphia.

Instead, he tells them, “Let's stop talking about quitting, and start talking
about treating the voice in your head that keeps you from doing what you want to do.”
This approach respects a smoker as someone “who both wants to quit and doesn't
want to,” and frames a prescription like varenicline as a way to “control
the instinct that keeps you from quitting,” Dr. Leone said.

Mental health issues can pose formidable barriers to tobacco cessation. A study of
397 inpatient smokers found that patients with comorbid depressive symptoms, alcohol
misuse, and heavy nicotine dependence were significantly less likely to quit smoking
after discharge than lighter smokers and individuals with smoking-related diseases
but no depressive symptoms or alcohol misuse.

Patients with mental and behavioral issues may express readiness to quit but need
more intensive interventions to do so, said study author Nancy Rigotti, MD, FACP,
director of the Tobacco Research and Treatment Center at Massachusetts General Hospital
and Harvard Medical School in Boston. She and her associates reported the findings
in the October-December 2017 Substance Abuse.

Physicians should consider all these factors but should look more broadly than “the
low-hanging fruit—the patients who have already decided to quit,” Dr.
Leone counseled. “It's impossible to identify who's not going to quit,” he said. “Even if patients go back to smoking, starting
treatment in the hospital means they will have started medications that catch up with
them. This will put the primary care doctor in a much better position to start outpatient
treatment.”

Tailoring therapies

Experts suggest that hospitalists start treating nicotine addiction at admission,
not discharge, and that they customize prescriptions by patient preferences and degree
of nicotine dependence.

All inpatients who use tobacco should be offered nicotine replacement therapy, which
can “ease them into a quit attempt,” said Dr. Melzer. Among more than
1,500 smokers admitted for exacerbation of COPD, inpatient replacement therapy significantly
increased the likelihood of receiving tobacco cessation medications at discharge and
using them afterward, she and her colleagues reported in the June 2016 Journal of General Internal Medicine.

Dr. Rigotti takes a similar approach. “In our experience, heavier smokers—those
who smoke more than 15 cigarettes a day—often require more than just a 21-mg
nicotine patch,” she said. “We often use a combination of a patch plus
nicotine inhaler, lozenge, or gum as needed to provide adequate suppression of cravings
in hospital.” Lighter smokers typically receive a 14-mg patch, and nondaily
smokers are offered nicotine gum, lozenge, or inhaler, which they can use when they
start to feel cravings.

Desire to quit can evolve during a hospital stay, so it's best to ask about intentions
closer to discharge, Dr. Melzer said. Data on prescribing smoking cessation medications
at discharge are mixed. In a study of more than 1,300 inpatient smokers with COPD
exacerbations, no single medication or combination significantly increased the chances
of quitting at 90 days compared with no treatment.

However, patients who received varenicline had more than twice the odds of quitting
as those prescribed the nicotine patch. Short-acting nicotine replacement therapy
was least effective, Dr. Melzer and her colleagues reported in the April 2016 Journal of Hospital Medicine.

“It's hard to know what to make of the lack of association between medications
and successful quitting from our observational study,” said Dr. Melzer. Patients
who received pharmacotherapy for tobacco use might have been more nicotine-dependent
in the first place or might have needed counseling or better titration of their medications
to control symptoms, she said.

Regardless, patient preferences should weigh heavily in discharge prescription decisions,
she said. “Patients who are strongly motivated to quit, but who want to be
able to smoke for a short period of time while they work on quitting, may do well
with [varenicline],” she said. Patients with concurrent depression might do
well with bupropion and nicotine replacement therapy, while those with dental problems
might wish to avoid nicotine gum, she added.

Fitting so many considerations into a packed hospital schedule requires creative solutions.
Massachusetts General Hospital has an opt-out tobacco cessation service, “which
is more efficient than trying to get staff to remember to order a smoking consult,”
Dr. Rigotti said. During the admission process, nurses fill out a 30-day tobacco history
that goes automatically to the tobacco treatment service.

Trained counselors then visit smokers at bedside to ensure adequate nicotine replacement,
offer help to quit, and provide discharge referrals to the state telephone quitline,
which provides free counseling and a sample of free replacement therapy.

This approach assists busy hospitalists who may not have time to do extensive counseling,
Dr. Rigotti said. For hospitals that lack dedicated smoking coaches, “nurses
are a great resource to provide counseling and remind physicians to treat nicotine
withdrawal,” she added. “Some smaller hospitals use respiratory therapists.
If the hospital has a pharmacist on the inpatient side, this is an ideal person to
teach patients about proper use of nicotine replacement and answer questions.”

Many other hospitals have support teams with specially trained pharmacists or tobacco
counselors who assess patients and recommend medications, Dr. Melzer said. Hospital
teams should develop clear processes for referring patients to smoking cessation resources
after discharge and starting them on medication in-house and at discharge, she added.
“Order sets that encompass decision support can be very helpful.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.